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1 New Claim Form, Posting Notice, and MPN Notices Effective 10/8/10 The Division of Workers Compensation (DWC) has released amended regulations that will take effect on October 8, Employers should replace all of their existing posters and begin handing out the new Notice of Potential Eligibility and DWC 1 Claim Form as of this date. Failure to provide current notices may result in DWC penalties. Due to these changes in the regulations the following forms have updated by the DWC: Employee Poster DWC 7 (English and Spanish) Notice of Potential Eligibility (English and Spanish) DWC 1 claim form (English and Spanish) Medical Provider Network (MPN) Employee Written Notification and Implementation Notices (English and Spanish) The MPN form changes do not affect currently enrolled employees. Copies of the above forms are available on and the DWC website. Employers who utilize new hire pamphlets should obtain revised versions through a preferred vendor, as these must also contain the amended language to reflect the change in regulations. These changes are designed to streamline and relieve the administrative burdens and costs in California s workers compensation system by allowing electronic distribution of MPN notices, reducing implementation and notice periods, reducing distribution of certain notices, including e- mail address for MPN contacts, and providing toll free contact number. Included is a helpful quick comparison guide of current and new MPN regulations. Also included below are helpful links:

2 Notice to Employees (DWC 7) MUST BE POSTED (8.5 X 14)

3 STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees--Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. There is a limit on some medical services. Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. Permanent Disability (PD) Benefits: Payments if your injury causes a permanent disability. Supplemental Job Displacement Benefit: A nontransferable voucher payable to a state approved school if your injury arises on or after 1/1/04 and results in a permanent disability that prevents you from returning to work within 60 days after TD ends, and your employer does not offer you modified or alternative work. Death Benefits: Paid to dependents of a worker who dies from a work-related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured and your physician must agree to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for your alleged injury and shall be liable for up to ten thousand dollars ($10,000) in treatment until the claim is accepted or rejected. 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesignated by naming your personal physician or medical group before injury (see above), you may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days. Different rules apply if your employer offers a Health Care Organization (HCO) or has a Medical Provider Network (MPN). You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. 4. Medical Provider Networks. Your employer may be using a MPN, which is a selected network of health care providers to provide treatment to workers injured on the job. If your employer is using a MPN, a MPN notice should be posted next to this poster to explain how to use the MPN. You can request a copy of this notice by calling the MPN number below. If you have predesignated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and your employer is using a MPN, you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer. If you are treating with a non-mpn doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: Current MPN s toll free number: MPN website: MPN Effective Date Current MPN s address: Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): Claims Administrator Phone Workers compensation insurer (Enter self-insured if appropriate) Policy Expiration Date If the workers compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards Enforcement (DLSE). You can also get free information from a State Division of Workers' Compensation Information & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll-free (800) Learn more information about DWC and DLSE online: or False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned. Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties. DWC 7 (6/10)

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